Reactive Attachment Disorder April Powell-Dodge Keystone College PSYC 314-01: Psychopathology Rick Shillabeer, Psy. D. To help us to identify what reactive attachment disorder is we will first need to define what attachment is. For the purpose of this paper, attachment will be defined as the reciprocal relationship between a child and caregiver (Robertson, 2000). The development of this relationship is dependent on the caregiver’s response to the child’s needs (Robertson, 2000). In order for a child to form a secure attachment, the child can “reliably experience security, comfort, and safety (Smith, 2006).
This attachment is dependent upon the child “perceiving the attachment figure as predictable, available and competent” (Smith, 2006). Nancy Geoghegan from the Attachment Disorder Site, 2000, illustrates what a healthy and secure attachment cycle should look like as well as what a disturbed attachment cycle looks like. Children with a disturbed attachment cycle will most likely be diagnosed with a reactive attachment disorder. Children with reactive attachment disorder have a different view of the world than we do.
They did not learn that they could trust adults to keep them safe. They, in fact, learned that adults were uncaring, mean, rejecting, violent, unreliable, unresponsive, or absent. Many children with reactive attachment disorder learn that they must take care of themselves and cannot depend on their caregiver to meet their basic needs. (Attachment Disorder Site, 2000) Reactive attachment disorder can be defined as a child’s inability to form a healthy functioning relationship with a primary care giver (Attachment Disorder Site, 2000). A child ith reactive attachment disorder typically is or has been neglected, abused or has been frequently moved from one caregiver to another never having the opportunity to establish a loving relationship with a caregiver (Mayo Clinic Staff, 2009). Attachment disorders are the result of negative experiences in the early years (Kemp, Smith 2010). Children with reactive attachment disorder are generally reacting to events that took place early in their lives (Attachment Disorder Site, 2000). Children with an attachment disorder lack trust and often feel unsafe and alone (Kemp, Smith 2010).
Children suffering from reactive attachment disorders come from families that have disregard for the child’s basic emotional needs for comfort, stimulation and affection and persistent disregard for the child’s physical needs (Robertson, 2000) According to the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2000) reactive attachment disorder begins before the age of five and the course varies dependent upon the individual child and caregiver and the severity of the neglect and the nature of intervention.
Sherpis, Doggett, Hoda, Blanchard, Renfro-Michel, Holiness & Schlagheck, 2003, report that the criteria for reactive attachment disorder is often difficult to process due to problems with differential diagnosis as well as disagreement among professionals regarding the etiology of reactive attachment disorder. Boris, Zeanah, Larriew, Scheeringa, and Heller report (as cited in Sherpis, et al, 2003) that the DSM-IV-TR has been critiqued for its focusing on reactive attachment disorder as a “maltreatment syndrome” focusing on problematic parental care and social oddities rather than a focus on the attachment issue.
The DSM-IV-TR offers the following as the diagnostic criteria for reactive attachment disorder: Diagnostic criteria for 313. 89 Reactive Attachment Disorder of Infancy or Early Childhood A. Markedly disturbed and developmentally inappropriate social relatedness in most contexts, beginning before age 5 years, as evidenced by either (1) or (2): (1) Persistent failure to initiate or respond in a developmentally appropriate fashion to most social interactions, as manifest by excessively inhibited, hyper vigilant, or highly ambivalent contradictory responses (e. . , the child may respond to care with a mixture of approach, avoidance, and resistance to comforting, or may exhibit frozen watchfulness) (2) Diffuse attachments as manifest by indiscriminate sociability with marked inability to exhibit appropriate selective attachments (e. g. , excessive familiarity with relative strangers or lack of selectivity in choice of attachment figures) B.
The disturbance in Criterion A is not accounted for solely by developmental delay (as in Mental Retardation) and does not meet criteria for a Pervasive Developmental Disorder. C. Pathogenic care as evidenced by at least one of the following: (1) Persistent disregard of the child’s basic emotional needs for comfort, stimulation, and affection (2) Persistent disregard of the child’s basic physical needs 3) Repeated changes of primary caregiver that prevent formation of stable attachments (e. g. , frequent changes in foster care) D. There is a presumption that the care in Criterion C is responsible for disturbed behavior in Criterion A (e. g. , the disturbances in Criteria A began following the pathogenic care in Criterion C). Specify type: Inhibited Type: if Criterion A1 predominates in the clinical presentation Disinhibited Type: if Criterion A2 predominates in the clinical presentation (p. 130)
The Mayo Clinic (2009) goes on to further describe the types of reactive attachment disorder as the inhibited type refuses relationships with anyone and everyone while the disinhibited type seeks attention from anyone and everyone, including strangers. Attachment disorders can fall on a spectrum of mild, insecure attachments to severe, known as reactive attachment disorder (Kemp, Smith 2010). Wood (2005) describes the two types of reactive attachment disorder as the inhibited type being emotionally withdrawn and the disinhibited type as being overly sociable.
Upon further research, Smith (2010) reports that there is an attachment disorder spectrum and identifies the following four categories of an attachment disorder: * Anxious Attachment Disorder – the child displays anxiety in connection to fear of abandonment: the child can be superficially charming; have high reports of lying; work to “manage” the adult * Avoidant Attachment Disorder – generally passive-aggressive; avoid physical contact; will typically say they have friends but do not socially respond to others Ambivalent Attachment Disorder – generally display anger and rage; show interest in fire, death and animal cruelty; incapable of giving affection; oppositional and demanding; * Neurologically Disorganized Attachment Disorder – behaviorally disorganized and unrelated to situation; unorganized thinking; unmanageable anxiety; attachment secondary to neurological factor Etiology The causes of attachment disorders widely varied and there are most often multiple contributing factors when the attachment process does not develop in a healthy manner (Smith, 2006).
Although the majority of attachment disorders are typically found in foster homes and in adoptions, the number of diagnosis’ in biological families is increasing (Smith, 2006). Parents of children with reactive attachment disorder have a disregard of the child’s basic emotional and physical needs (American Psychiatric Association, 2000). Infants and children that are most likely to be affected by reactive attachment disorder “come from abusive families or were raised in foster care or orphanages” (Wood, 2005).
This is because these children lack the stability of a consistent care giver and therefore the ability to establish a secure, loving attachment during infancy and early childhood (Wood, 2005). Children suffering from reactive attachment disorder do not have their basic emotional and physical needs met as an infant or young child; these needs are not met with a shared emotional exchange; the needs of the child are often ignored or are met with physical and/or emotional abuse (Mayo Clinic, 2009).
If the needs of the child are not appropriately met, the child will become distrustful of the caregiver and will avoid interactions with the caregiver (Mayo Clinic, 2009). The attachment disorder site goes on to identify additional potential causes of reactive attachment disorder as neglect, abuse, separation from the primary caregiver, changes in the primary caregiver, frequent moves and/or placements, traumatic experiences, maternal depression, maternal addiction – drugs or alcohol, undiagnosed, painful illness such as colic, ear infections, etc. , lack of attunement between mother and child, and young or nexperienced mother with poor parenting skills. Situations that may increase the likelihood of a diagnosis of reactive attachment disorder include living in an orphanage, institutional care, frequent foster care placements, extreme poverty, abuse and family trauma (death, disease) (Mayo Clinic, 2009). Symptoms Kemp & Smith, 2010, identify common signs and symptoms of reactive attachment disorder as, an aversion to touch and physical affection, control issues, anger problems, difficulty showing genuine care and affection, and an underdeveloped conscience.
Wood (2005) identifies children with reactive attachment disorder as being impulsive, aggressive, having erratic mood swings, oppositional behaviors, emotional withdrawal and self-injurious behaviors. Mayo Clinic Staff (2009) identifies children as being withdrawn, having no interest in toys or people, failure to smile, avoidance of comforting gestures, aggressiveness and limited social interactions.
The attachment disorder site advises parents and caregivers to look for the following signs in identifying a child with reactive attachment disorder: intense control battles, very bossy and argumentative; defiance and anger, resists affection on parental terms, lack of eye contact, especially with parents – will look into your eyes when lying, manipulative – superficially charming and engaging, indiscriminately affectionate with trangers, poor peer relationships, steals, lies about the obvious, lack of conscience – shows no remorse, destructive to property, self and/or others, lack of impulse control, hyper-vigilant/hyperactive, learning lags/delays, speech and language problems, incessant chatter and/or questions, inappropriately demanding and/or clingy, food issues – hordes, gorges, refuses to eat, eats strange things, hides food, fascinated with fire, blood, gore, weapons, evil, very concerned about tiny hurts but brushes off big hurts, parents appear hostile and angry, the child was neglected and/or physically abused in the first three years of life.
Because of the various attributes to a child with an attachment disorder, many children are not necessarily misdiagnosed, but are “partially diagnosed” (Smith 2006). Upon evaluation, many examiners will focus on one of the contributing attributes and not fully diagnosis a child with having an attachment disorder (Smith, 2006). Co-morbidity The early signs and symptoms of reactive attachment disorder are similar to the early signs and symptoms of other mental health issues such as attention deficit hyperactivity disorder and Autism (Kemp, Smith 2010).
Reactive attachment disorder is also closely related to “conduct disorder, oppositional defiant disorder, attention deficit disorder/attention deficit hyperactivity disorder, and the development of antisocial personality disorders (Sheperis, et al, 2003). The DSM-IV TR (2000) also states that not unless a diagnosis of mental retardation or pervasive development disorder can be ruled out, reactive attachment disorder is not diagnosed. Reactive attachment disorder can also display many of the signs and symptoms of social phobia, ttention deficit hyperactivity disorder, conduct disorder, and oppositional defiant disorder (American Psychiatric Association, 2000). Smith (2006), reports that the aspects of a child with an attachment disorder can be found in Attention Deficit Hyperactivity Disorder, Oppositional Defiant Disorder, Conduct Disorder, Separation Anxiety Disorder, Generalized Anxiety Disorder, Post Traumatic Stress Disorder, Dysthymic Disorder/Major Depression and Bipolar Disorder/Cyclothymic Disorder. Statistics
According to the DSM-IV, TR (2000) data is limited, but reactive attachment disorder appears to be very uncommon. Reactive attachment disorder is a serious condition that affects infants and young children (Mayo Clinic Staff, 2009). It is a condition that is rare and affects both boys and girls; however, no accurate statistics on how many babies and children have the condition is available (Mayo Clinic Staff, 2009). It is not known why some children develop reactive attachment disorders and others don’t (Mayo Clinic Staff, 2009).
As mentioned above by Smith (2006), attachment disorders are often “partially diagnosed” so therefore it would be difficult to determine the actual number of actual of children with a diagnosis of attachment disorder. Treatment The earlier attachment issues are identified, the easier they are to resolve (Kemp, Smith, 2010). Treatment of attachment disorders usually includes both the child and the caregiver (Kemp, Smith 2010).
The treatment of reactive attachment disorder generally involves both psychological counseling and parent/caregiver education; treatment is long-term and very demanding (American Psychiatric Association, 2000). Medications are often used as treatment of other present symptoms such as depression, anxiety or hyperactivity (American Psychiatric Association, 2000). Treatment of reactive attachment disorders can be challenging as the children are distrustful and feel unsafe. They keep their guard up to protect themselves while preventing them from accepting love and support (Kemp, Smith 2010).
One needs to establish clear expectations and rules of behavior and provide consistency so the child will know what to expect under any circumstance (Kemp, Smith 2010). Kemp and Smith offer the following advice for making your child feel safe and secure: 1) Set limits and boundaries, 2) take charge, yet remain calm when your child is upset or misbehaving, 3) be immediately available to reconnect following a conflict, 4) own up to mistakes and initiate repair, 5) maintain predictable routines and schedules. The goals of Treatment is to help ensure that the baby or child has a safe and stable living situation and that he or she develops positive interactions with parents and caregivers” (Mayo Clinic Staff, 2009). Robertson (2000) recommends the following therapeutic approaches to reactive attachment disorder play therapy, cognitive behavioral therapy, and reality therapy. Therapy for the child with a reactive attachment disorder needs to be child centered and need centered (Robertson, 2000).
Each child needs to be looked at as being different and each child’s specific needs will need to be addressed. Therapy needs to be interactive and conducted in an age appropriate way. Some unproven treatments for reactive attachment disorder provided by the Mayo Clinic Staff, 2009, include: 1) Re-parenting, rebirthing, 2) Tightly wrapping, binding or holding children, 3) Withholding food or water, 4) Forcing a child to eat or drink, 5) Yelling, tickling or pulling limbs, triggering anger that finally leads to submission. Beware of mental health providers who promote these methods. Some offer research as evidence to support their techniques, but none has been published in reputable medical or mental health journals” (Mayo Clinic Staff, 2009). Prognosis “If you’re a parent or caregiver whose child has reactive attachment disorder, it’s easy to become angry, frustrated and distressed. You may feel like your child doesn’t love you — or that it’s hard to like your child sometimes” (Mayo Clinic Staff, 2009).
The Mayo Clinic, 2009, offers the following advice to parents and caregivers of children with reactive attachment disorder: 1) Educate yourself about attachment issues, 2) Take classes or volunteer with children, 3) Be actively engaged with your child, 4) Learn to interpret you child’s cues, 5) Provide warn, nurturing interactions with your child, 6) Teach children how to express feelings and emotions with words, 7) Offer both verbal and nonverbal responses.
Tully and Brendtro (1998) provide 10 steps designed to address the issues of attachment disorders in children that have been removed from their primary caregiver, 1) Create a safe environment – “you won’t get hurt here”, 2) experience the child’s rage – “boy , are you mad”, 3) connect the rage to its source – “who are you mad at? , 4) enhance self-worth – “you are a person of great value”, 5) retracing the abuse – “returning to the scene of the crime”, 6) relieving the feeling of responsibility –“it’s not your fault”, 7) attachment – “falling in love”, 8) family decisions – “to go home or find a new home”, 9) transition to family – “go slowly”, and 10) healthy farewells – “crying time”.
Complications from reactive attachment disorders can continue into adulthood such as poor self-esteem, delinquent anti-social behavior, relationship problems, anger problems, eating disorders, depression and anxiety, drug and alcohol abuse, and/or inappropriate sexual behavior (Mayo Clinic Staff, 2009). “With the right tools, and a healthy dose of time, effort, patience, and love, attachment repair can and does happen” (Kemp, Smith, 2010). Reactive attachment disorders are a lifelong condition but with treatment, hildren can develop healthy relationships with others (Mayo Clinic Staff, 2009). References American Psychiatric Association. (2000) Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision, pp 127-130. Washington, DC. Attachment Disorder is a wonderful website for information on Attachment Disorders (http://www. attachmentdisorder. net). Kemp, M. A. , G. , & Smith, M. A. , M. (2010). Attachment Disorders & Reactive Attachment Disorder. Retrieved Nov. 18, 2010, from HelpGuide. rg, Pacific Palisades, CA. Website: http://www. helpguide. org/mental/parenting_bonding_reactive_attachment_disorder. htm. Reprinted with permission from Helpguide. org © 2001-2010. All rights reserved. For more information, visit www. Helpguide. org. Mayo Clinic Staff. (2009). Reactive Attachment Disorder. Retrieved Nov. 18, 2010, from Mayo Foundation for Medical Education and Research, Scottsdale, AZ. Web site: http://www. mayoclinic. com/health/reactive-attachment-disorder/DS00988. Robertson, M. Ed. A. (2000) Reactive Attachment Disorder: What we need to know to help [Lecture Notes]. Retrieved from Northwestern Human Services Sheperis, C. J. , Doggett, R. , Hoda, N. E. , Blanchard, T. , Renfro-Michel, E. L. , Holiness, S. H. , & Schlagheck, R. (2003). The Development of an Assessment Protocol for Reactive Attachment Disorder [Electronic version]. Journal of Mental Health Counseling, 25(4), 291-311. Smith, LCSW-C, LICSW, L. B. (2006, June). Attachment Disorder. In attachmentdisordermaryland. com.
Retrieved November 26, 2010 Smith, LCSW-C, LICSW, L. B. (2010, February). The Attachment Disorder Spectrum. In attachmentdisordermaryland. com. Retrieved November 26, 2010 Tully, F. G. , & Brendtro, L. K. (1998). Reaching Angry and Unattached Kids. Reclaiming Children and Youth, 7(3), 147-155. Wood, M. E. (2005, March). Reactive Attachment Disorder: A Disorder of Attachment or of Temperament? Rochester Institute of Technology, 1-15. Retrieved from http://www. personalityresearch. org/papers/wood/html